The sharp splintering pain of shin splints makes you stop in your tracks. Every time you feel ready to try a longer hike or a faster run, your shin pain is right there waiting for you. Also known as medial tibial stress syndrome, shin splints is an overuse injury that happens if you do too much too soon. Especially after doing too little for too long.

Even though the pain settles with rest, rest alone won’t solve the problem. If left untreated and ignored, the continued bone stress on your shin will ultimately lead to a tibial stress fracture.

Shin splints, or medial tibial stress syndrome, is a cumulative bone stress disorder. In other words, it doesn’t happen overnight, but rather from repeated loading on your shin without enough rest. Many people underestimate how important rest is, but the recovery time in between exercise is crucial for your body to naturally repair and restore the bone.

Ignoring your shin pain, means a gradual weakening of the area and the constant pounding causes minute cracks in the bone. Your body can repair the cracks if given enough time to rest and recover. However, if you don’t rest, the tiny cracks progress to a complete stress fracture.

Shin splints is a general term describing the pain felt over the front of your lower leg. It usually happens during or after exercise, but can also occur after walking a long distance or up a steep incline.

But why does it happen? The muscles and tendons attached to your shin bone control your ankle movements and distribute the load, or stress, over the soft tissue, bone and joints. For instance, when you jump, the muscles and tendons not only lift your feet off the floor, but also help to absorb and distribute the impact when you land. Otherwise your whole foot will hit the floor after every hop. That’s just one example of how the muscles and tendons should work together to decrease stress on your shin bone.

Things start to go wrong when the non-stop strain on your shin leads to inflammation, swelling and muscle spasm. The constant tension of your calf muscles on your shin results in small tears in the tendons and inflammation of the bone. This local reaction increases the pressure on the bone even more, resulting in a vicious cycle of inflammation and pain.

• Increasing the intensity of your training i.e. too fast, too far, too soon.
• Stop-start activities, e.g. running, tennis, soccer.
• Repetitive high impact landing.
• Running on uneven ground, down a slope or incline.
• Tight calf muscles.
• Running on hard surfaces e.g. running barefoot on a tar road.
• Worn out shoes.
• Flat feet.
• High BMI.
• Calf muscle weakness.
• Tight hip muscles.

At first, your shin pain won’t bother you all that much. You will notice some tightness in your calf muscles, and an ache over your shins when you run. In the early stages of shin splints, this ache goes away when you warm up and only the tightness in your muscles remains. For now, you can easily ignore your painful shins.

After awhile, the dull ache becomes definite discomfort when you exercise. As soon as you pick up the pace on your run, the sharp, burning pain makes you slow down. The more you run, the worse it gets, until you have to slow down to a walk to get back home. The pain takes longer to settle after each run, and the tightness in you calf muscles is your constant companion. Your shin pain feels better the morning after training, but pressure or a bump against your shin makes you take notice of your unhappy shins.

If left, untreated, this constant discomfort turns into severe pain that keeps you from falling asleep at night. Even just walking fast is painful now, not to mention walking up an incline. Any pressure on your shin is excruciating and the whole front of your shin feels swollen and inflamed. Running at any pace is impossible due to pain, and the thought of jumping will make you cringe.

Through a physical exam, our physiotherapists diagnose the cause(s) of your shin pain and advise you on the right treatment plan for your problem. We perform a number of tests including stress tests, muscle length testing, neuromuscular control and neural tests to find the root cause of your shin splits. A tuning fork is a useful, non-invasive tool we can use if we suspect a stress fracture. If your pain gets worse when the tuning fork is placed on the injured area, this will raise our suspicion that you have a stress fracture. Even though this test isn’t definitive, a negative test can be up to 92% sensitive to exclude a stress fracture.

X-rays are not useful to diagnose medial tibial stress syndrome. If your shin pain has already progressed to a stress fracture, an x-ray might show periosteal thickening as the injury starts to heal. However, a normal X-ray does not exclude a tibial stress fracture.

From a physiotherapy point of view, an ultrasound scan is more useful as a diagnostic tool, apart from our clinical assessment. Although an ultrasound doesn’t show the bony elements, it does visualize swelling around the bone, indicative of either a stress fracture or shin splints.

An MRI scan shows all of the structures in your lower leg, including soft tissue, bones, nerves and blood vessels. In the case of a stress fracture, this scan will show an inflammatory reaction and swelling of the bone. However, these scans are extremely costly and usually not necessary to diagnose shin pain.

Also known as scintigraphy, this imaging is less expensive than an MRI, and can also be used to confirm a stress fracture. However, scintigraphy is more invasive, because it involves injection of a radioactive chemical. Specialized equipment detects the radiation from this chemical, and a computer forms an image. If there is a stress fracture, that area of the bone will show increased uptake of the radioactive chemical.

The first rule of shin splints is to rest your leg. Take away the aggravating factor. That doesn’t mean you can’t do any form of exercise, but you have to rest from the thing that originally caused your pain. Shin splints is your body’s way of showing you that you are doing more than it can handle. We usually see people come back over and over again due to shin splints, because:

• They are not resting as recommended.
• Not doing their home exercise protocol.
• Failure to complete their rehabilitation program.
• Going back to their sporting activity too soon.
• Increasing how hard they train when the pain settles.
• Using medication to numb and ignore the pain while they keep training.
• Not paying attention to their nutrition.

Fractures are the most common complications we encounter from patients who have ignored their shin pain for too long.

Stress fracture

There are two major causes of stress fractures. These are when an abnormal force is placed on a normal bone, or when a normal force is placed on abnormal bone.

Abnormal force means that the force you apply is more than what your body can handle. Most commonly this is overtraining over a prolonged period of time. Abnormal bone means that there is something wrong with the bone itself. Examples are low bone density, osteoporosis, osteochondritis, and the female triad seen in very active female athletes.

Tibia fracture

A fracture is the worst case scenario of ignoring shin pain. This happens when you don’t stop activity that caused the shin splints in the first place. Where a stress fracture is a line fracture within the bone, like a small crack, a tibia fracture is where the crack turns into and actual fracture. In other words a broken bone. This happens when you do not comply with the rest and treatment advised. Unfortunately, the recovery process for a tibia fracture is much longer than shin splints, and includes a period of immobilization where we have to take all the weight off of your leg. You will be in a cast or moon boot for 6-8 weeks, and on crutches until the fracture has healed. So it really is worth listening to your body at the very first signs of shin splints!

Although rest is crucial in the early days with shin splints, too much rest leads to a basket of other problems like joint stiffness, muscle weakness, tightness and impaired proprioception.

Your physiotherapist is an expert when it comes to guiding you in finding the balance between rest and activity. The key is load management, not taking all the load away. In the first week after your injury, this means mostly resting, but as soon as the pain settles we need to start gentle movements. After all, movement is medicine. This will include low impact exercises, like gently moving the joints around your knee and ankle.

As medical professionals, physiotherapists have a wide range of treatment modalities and techniques to help you through each phase of healing. These include modalities like dry needling, laser to stimulate healing, strapping to relieve stress on the bone, soft tissue mobilization and myofascial release to treat tightness and restrictions and, of course, gradual increase in load to make sure your shin bone is prepared for your day to day activities.

The minimum recovery time includes a resting period of 2 to 4 weeks from any sport or exercise. Alternatively, you can switch to other low impact activities (e.g. such as swimming or cycling). Shin splints takes 8 to 12 weeks to heal. This may sound like a long recovery period, but a full blown tibial stress fracture takes between 3 to 6 months to heal.

In the first phase of treatment we will need to see you twice a week for pain management and to protect the injured area. Thereafter, we will see you once a week to add a loading protocol and continue pain treatment. When your pain settles, we will see you once every second week to monitor your progress and healing of your shin splints.

• Your doctor (GP) can prescribe pain medication, if needed.
• There is an association between malnutrition and stress fractures, so seeing a dietician or nutritionist is also important is you have low BMI.
• Getting your ankle ‘aligned’ or ‘clicked’ will not improve the state of your shin bone.
• A biokineticist will be able to help you in the final stages of your rehabilitation and get you back to training for your sport.
• Immobilizing your ankle in a moon boot is helpful if you have severe pain with walking.
• Foam-rolling is not advisable for shin pain, especially if you don’t have a diagnosis.
• Crutches may also be useful in the acute phase if you have pain putting weight on your leg.

Non-surgical treatment like physiotherapy is the first choice for shin splints. Only if your pain doesn’t resolve with non-surgical options, invasive options like surgery might be considered. This involves a deep posterior compartment fasciotomy to release the soft tissue causing traction on the shin bone.

However, surgery is still only the beginning of the recovery process. You will need to address the original, underlying causes that led to your shin pain.

• Tibia fracture – maximal tenderness over a specific spot on the shin bone.
• Fibula fracture – point tenderness over the side of your lower leg.
• Exertional compartment syndrome – pain always starts after the same amount of time exercising. May also have numbness, weakness and pins ‘n needles in your lower leg.
• Tibial fracture – any weight on the leg is painful and doesn’t get better with rest.
• Tibialis posterior tendinopathy – pain more concentrated over the inner part of your ankle and arch of your foot.
• Sural nerve entrapment – burning pain, numbness or pins ‘n needles over the inner part of your lower leg.
• Popliteal artery entrapment – changes in skin color and temperature, severe aching pain in your lower leg.
• Tibialis anterior strain – walking on your heels makes pain worse.

• Medial tibial stress syndrome
• Shin pain
• Traction periostitis
• Medial tibial traction syndrome
• Lower leg pain
• Anterior tibial pain
• Tibial periostitis